The Unlikely Addicts

Many think of Valium as ‘mother’s little helper’, blue pills popped by harried housewives in the 1960s and 70s. Yet the drug’s effects are still being felt as long-standing addictions – often among Australia’s elderly.

QWeekend Magazine, The Courier Mail, May 2014

There was something about Mary. When I was little and my grandmother would smile at me, I could see almost every tooth in her mouth. She wore colourful beads from Morocco and France. They looped down to her breasts and knocked against her blouse when she spoke. Her laughter would crackle through the air like fireworks. She was a party that I always wanted to stay up late for.

I was a teenager when the wind changed. Mary’s personality grew wild and wintery. She would lash out at family and slur words over dinner. ‘It must be the drink,’ I thought. The ritual draining of her wineglass became a play that would start serenely enough, but end in calamity.

One night she thudded her fists against the table, a drumbeat to accompany her off-key singing and insults flung at my grandfather. “What would you know? Nothing!” she hollered, before crumpling into her seat.

Things fell apart further. On a separate night, my aunt Marianne says Mary “tripped all over the place when she was trying to go to bed.” Not long afterward, she suffered a car accident on the way home from our house. She gave up her license immediately. Later still, Mary fell in her driveway, badly damaging her back.

My father John pieced together the puzzle when eventually she needed help getting to GP appointments. “I’d sit beside her and Mum would ask outright for Valium scripts. I should’ve worked it out sooner. She’d been taking it for years.” Forty years in fact.

‘Valium’, or Diazepam, is a benzodiazepine. This class of tranquilising drugs includes Alprazolam, better known by the brand name ‘Xanax’.

‘Benzos’, as they’re called colloquially, bind to an inhibitory receptor in the brain, thereby relaxing the muscles and sedating the mind. The drugs are big business. Seven million benzo scripts are written nationally each year, says the Royal Australasian College of Physicians.

Mary was first prescribed Valium by her family doctor. It was the 1970s. She was menopausal and had suffered a rough patch in her marriage with my grandfather, a civil engineer and workaholic.

“This new wonder drug came out, and it was meant to help people with depression and sleeplessness. Our family doctor was a good friend. He put her on it, and she stayed on it until she died,” says Marianne.

“Towards the end, when she was in the nursing home, she asked me, ‘Have I done this to myself?’ I said, ‘Of course not, Mum.’ But to be honest, I thought she had done. The ramifications were often horrible.”

Among the organisation’s benzo program patients, two-thirds are women. Eight per cent have taken benzos for twenty years or longer. Reconnexion counselor and social worker Stephanie Twaites says: “Our clients are unlikely. They’re not the sorts of people who would usually fall into the drug and alcohol category.”

The University of Tasmania’s Dr Juanita Westbury researches benzo use in nursing homes. She says that around one in four Australian residents take the drug. In this arena, figures from Queensland nursing homes sit roughly in the middle when compared with those of other states. “Queensland is not the best, and it’s not the worst,” she says.

The issues arising from nursing home benzo use, however, are common countrywide. “Older benzo users sleep more during the day and statistically have increased risk of falls,” Westbury says. “Often if someone is on benzos they don’t engage as well with nursing home staff, or with their families. They’re prone to ‘going off’ at people. We hear relatives saying, ‘I don’t want my loved one taking this drug.’” When I read this quote to my dad, he nods and exhales slowly. “We know all about the side-effects, don’t we?”

Benzo users, says Twaites, often come in two sizes. There are young users. But more often users are older people. They started taking the drugs in their twenties or thirties, then kept going. Like Mary, those from this latter group – the bulk of Reconnexion’s patients – were advised to take a benzo for anxiety or sleep issues. “They get prescriptions. They’ve become dependent and doctors have continued to prescribe them the benzo,” Twaites says.

A 2013 study in the Medical Journal of Australia confirms her observation. It found that among 305 rehabilitation patients hailing from Queensland, Victoria, Western Australia and Tasmania, 78 per cent of benzo addicts sourced drugs from doctors.

As lead author Dr Suzanne Nielsen from the National Drug and Alcohol Research Centre tells Qweekend: “Dispensing statistics show that older people are getting benzos more commonly. And something that we’ve heard quite a lot is that people don’t know these medications aren’t meant to be used long-term.”

Consumer product information from Valium’s manufacturer Roche Pharmaceuticals suggests use not exceed four weeks. Yet dependence can develop within that timeframe, or even earlier, Twaites says. “Valium isn’t recommended for people over the age of 65 anyway.” Slower digestive systems can allow the body to build up stores of the drug, which in turn affects memory as well as muscle coordination.

A 2012 British Medical Journal study raised more serious concerns still. “This research crystallised data about harms from benzodiazepines,” says Dr Christian Rowan, President of the Australian Medical Association Queensland.

The study noted that hypnotics – medicines that trigger sleep or partial loss of consciousness – lead to raised incidence of cancer malignancy, heart disease and death.

Some users sense these dangers intuitively. They get a ‘bad hunch’ about a benzo drug early on. My aunt Marianne, now in her sixties, briefly took Valium during a bout of low mood. She stopped almost immediately. “Mum used to say how great she felt while she was taking Valium, but I felt awful, like a Zombie.”

Dr Marie Porter, 75, is an author and Honorary Senior Research Fellow at the University of Queensland. She took benzos for a year before deciding to withdraw.

“I was in my early 40s and a mother to three boys. My 12-year-old Anthony was totally physically handicapped. The specialists told me he’d never live to age one. But I made up my mind that wasn’t going to be the case,” she says.

“We worked so hard. Not just me, the whole family. I got to the stage where I couldn’t sleep at all and I could hardly think clearly. I once put on a dress back-to-front and wondered why it looked strange.”

Marie’s doctor referred her to a psychiatrist who put her on “maximum doses” of two benzos, Serepax and Rohypnol. “I was in and out of hospital for a year. I got to a stage where I thought, ‘This is just masking things. I need to get off these pills.’ So I stopped. My doctor was absolutely incredulous that I could do that. He asked me what happened. I told him I shook and cried for a day, but I coped.”

Marie was one of the fortunate ones. In some cases Benzo withdrawal can take two years and involve headaches, memory loss, slurred speech, feelings of confusion, emotional detachment and flu-like symptoms.

Among the benzo users Twaites sees, many were not initially informed of its addictive potential, nor offered counselling support. “The issue behind taking the drugs in the first place was never really treated – whether it was insomnia or panic attacks.”

University of Queensland epidemiologist Professor Jake Najman has monitored state-specific medication use since 1983. Among his long-term study participants, all of whom are female, 30 per cent report having experienced a mental health issue, mainly anxiety or depression.

On the day he spoke to Qweekend, Najman says: “In the last week, 23 per cent have taken a prescribed medication. That included different medications like benzos Valium and Temazepam. Extraordinarily, over 50 per cent report they’ve self-medicated in the last week.” His figures include complementary medicines, as well as over-the-counter and illegally sourced drugs. “It’s like almost everyone is doing it.”

Says Rowan: “I absolutely do see benzo dependence as an issue in Queensland. There is an abuse potential, and that’s why Alprazolam [was] upscheduled to a Schedule 8 [S8] drug.” This will mean that physicians need Department of Health authorisation before prescribing the medicine.

Like Twaites, Rowan opposes what he deems Australians’ predilection to ‘fix things with a pill’. “Sometimes it’s easy to look for a quick solution. I call it part of the McDonalds-isation of society,” he says. “For things like sleep issues and anxiety, benzodiazepines do have place in medical management. But only in the short term. First you often need to try psychological and non-medical strategies. The issue could be stress at work or constant connectivity to technological devices. If people begin taking tablets for things like that [stress and insomnia], it can mask the real issue.”

Yet in some cases, especially among illegal users, band-aid solutions are precisely what’s sought. Marketing officer and Australian resident Annika*, 26, first bought Valium in her home city of Kilkenny, Ireland. She’s now switched to other benzos, including Xanax and the sleeping pill Zolpidem. The shift partially occurred due to the difficulty in sourcing Valium in Australia, especially in comparison to the UK or South East Asia, where three years ago she bought tablets as little as five cents each.

“I started taking Valium about the time my dad got sick with cancer. I had a contact in Ireland who stole them direct from the factory. I just wanted to blot out my life. It was a struggle and I didn’t want to deal with it. In the beginning, I’d get up, go to work, come home, have a bottle of wine and a Valium and that was it. I would wake in the middle of the night, and reach over and have one, too.”

Just as other users report, however, Annika had trouble in limiting her dose. “Things got to the point where I was having about six to seven Valiums a night. I felt fine, but my friends said I’d slur my words and look out of it. I remember buying up to 100 over the counter in Laos and Cambodia. I got into the same routine, all over Asia. My friends were on at me, but there was no talking to me. Now I can’t remember chunks of our trip.”

By the end of her holiday, Annika’s bags carried just five remaining pills that she discarded before passing through Brisbane Airport. In the two years since her holiday, she’s developed a better sense of the local drug scene. Annika reports that young people in Australia use Xanax the way that the Irish use Valium: “to help take the edge off a big night, to calm down and to fall asleep”.

Xanax is the Valium story all over again, “but much worse because of its short half-life,” argues an anonymous University of NSW medical historian interviewed for this story. She explains that Xanax is just as addictive as Valium, yet more dangerous because the body processes the drug faster, hastening the need for subsequent doses.

“Xanax is almost too good a drug for anxiety,” says Don Woollard, 55, a former library technician with social anxiety. Don started taking Serepax in his twenties. He later switched to Xanax to cope with the stress of study.

“Xanax kicks in quickly. It takes about 20 minutes, and will last for roughly four hours. The problem lies with tolerance and dependence. A tolerance develops quite quickly, or at least it did with me. Instead of one tablet you need two to get the same effect.”

After nine years on Xanax, Don is now anxiety drug-free. Though he says his memory and cognition are shot. “I know people who still use benzos. Some maintain that they can control the dosage. If that’s the case, I can see how benzos can be effective. But I have no experience with that. I could never control the dose. They make you feel so good that you just want to feel that way all the time. And you’ll do pretty much anything to get more.”

Christian Rowan sees the Valium and Xanax stories as having similar plots, yet different cast members. “I think of the Valium story as middle age women managing distress – ‘My doctor gave me Valium to put me out of my misery’. While Alprazolam users are younger and seeking more intoxication, more 'out of it-ness'.”

Perhaps on account older user demographics, as well as heightened GP awareness of addiction pitfalls, national Valium use is slowly declining. Queensland’s usage figures are static. But on a state and federal level, Alprazolam use has spiked. And that’s despite difficulties users face in finding doctors willing to prescribe the drug – a task that will be made harder still on account of Xanax’s S8 reclassification.

“It’s embarrassing asking doctors for it,” says Annika, who sought a Xanax script from a surgery in Sydney’s Bondi Junction just prior to the drug’s upscheduling. ‘No Xanax prescribed here,’ read a sign sticky-taped to the window.

Late last year Xanax’s manufacturer Pfizer announced it would stop supplying the drug in Australia. The company predicted the S8 move would affect its bottom line. However, with two-thirds of Alprazolam currently taken in generic form, the decision is unlikely to affect supply.

Stephanie Twaites suggests the rules surrounding benzo prescribing be restricted and extended further. Before receiving prescriptions, patients could be screened, she says. Similarly, a permit system could be applied to doctors prescribing benzos of all shades.

“Maybe doctors don’t have the time or the skills to screen people about what’s really going on. But benzo use needs to be talked about more. It feels like there’s still a lot of silence around these issues.”

A 2011 review from the Institute of Psychiatry at King's College in England entitled ‘Benzodiazepines revisited – will we ever learn?’ reiterates Twaites’ sentiments insofar as they apply to the United Kingdom. It argues, “The practical problems with benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies.”

Australian GP attitudes to benzo prescribing remain spilt – partially due to the spectrum of patient reactions to the drug. While a proportion tolerate benzos well, others incur addictions so severe that they become other people entirely, says addiction medicine specialist and GP, Sydney-based Dr Andrew Byrne. “They lurch between episodes of varying intoxication and withdrawal which often involve aberrant behaviour, legal infractions and occasionally injuries or death.”

As a result, Byrne supports calls for high-potency benzos to be banned nationwide. He instead advocates prescribing low-dose, long-acting benzo drugs. This is provided GPs follow safeguards such as supervising doses, treating underlying issues and taking urine tests to ensure compliance with an agreed-upon course of treatment.

Presently, GPs receive insufficient guidance on how to stabilise addicted patients. Byrne argues that professional bodies like the Royal Australian College of General Practitioners need to urgently provide physicians with more detailed direction on ‘best practice’ benzo prescribing.

Dependency rates could be further eased by encouraging doctors to monitor and regularly review patients, adds Dr Christian Rowan.

Qweekend spoke to a Canberra-based GP who says responsibility for ongoing benzo dependence rests too with the prescribing culture at medical ‘super-centres’. Doctors who operate in smaller community practices develop long-term relationships with patients. He believes this places them in a better position to more easily recognise someone hunting a quick script, and thereby refuse one if necessary. “GPs working in super-centres see high volumes of patients for short consultations. People are in and out. Here, doctors are sometimes less diligent in spotting addictions and in saying ‘no’ to issuing scripts.”

Speaking about nursing home benzo dependence, Juanita Westbury says issues often relate to resources, or lack thereof. “Part of the problem is that everyone blames everyone else as to why residents are on it. If you ask the doctors, they say the nurses ask for it. Nursing staff say that patients ask for it. It’s sometimes easier for staff to deliver a pill than it is for them to sit down with residents. This is a problem that would ease with better resources,” she says.

In late March, Alzheimer’s Australia found that 80 per cent of dementia patients in nursing homes take psychotropic drugs, though only one five patients benefit from doing so. A federal senate committee inquiry held the same month found an “over-reliance on medication to manage the behaviour of residents”.

Yet Westbury contends that despite all the attention, little is being done to stem use of the drug collective, benzos included.“Often [nursing home] staff believe that benzos will help with a patient’s quality of life. But if you’re asleep half the day, or you fall while you’re under the effect of a benzo, then it doesn’t patients’ improve quality of life at all.”

When I think about Mary’s final years, Westbury’s words ring true. Benzo addiction dulled my grandmother. It pulled the fireworks from her sky.

Marianne agrees. She winces when recalling that before passing away three years ago, Mary would plead for her drugs. “The way mum would ask for her Valium was heart-breaking.”

She says: “Like many women of her generation, mum just didn’t have the emotional capacity to stand back and ask what was going on, to talk about what was beyond the addiction and to confront it. There was a lot of guilt and shame. Things were kept hidden.”

After Mary died I spoke to my dad about her mood swings. I learnt that my grandmother wasn’t drunk on those nights we shared dinner. In truth, she was also drugged. And in so being, she wasn’t here with us, or with me. Mary was just Mary. Not nana, the woman whose laughter I loved more than summer holidays, or whose toothy smile fired my heart’s electrical grid.

In January, on roughly the day she would’ve turned 92, my dad waded through some of Mary’s belongings. He rang to tell me what he’d found. “There are packets and packets of nana’s Diazepam here. They’ve expired of course.” There were loose notes, too. But one stood out from the rest. I asked him what she’d written. It was list of things to remember – a page crowned by capital letters that weaved the word ‘Valium’.

*Name changed to protect identity

THE BENZO TIMELINE

1955

Hoffmann-La Roche chemist Leo Sternbach identifies the first benzodiazepine, later released as the anxiety drug ‘Librium’

1960

Librium launches in Australia with the slogan, ‘No matter what the diagnosis – Librium!’

1963

Valium hits Australian shores, with widespread marketing on radio, billboards and in women’s magazines

Valium’s turns 40. To mark the occasion, Roche unfurls a banner reading, ‘Thanks for the relaxation and happiness you’ve given us over the years’

2008

The benzos Diazepam (Valium), Temazepam and Alprazolam (Xanax) are officially implicated in the death of Australian actor Heath Ledger

2010

The Royal Australasian College of Practitioners reports sales of Alprazolam rose by 28 per cent on the previous year

2011

Valium is detected in the bodies of 72 per cent all Scottish drug-related deaths

2013

Pfizer announces it will no longer distribute Xanax in Australia. Seven million benzo scripts are written nationwide

February 2014

The TGA upgrades Xanax from a Schedule 4 to a Schedule 8 ‘drug of dependence’. The Pharmaceutical Benefits Scheme removes Xanax from its registry. All other benzo drugs, including Valium, maintain ‘prescription only’ classification.